Use of complementary and alternative medicine in pediatric otolaryngology patients attending a tertiary hospital in the UK

OBJECTIVE: Little data is available on complementary and alternative medicine (CAM) use in children attending otolaryngology services. We investigated the prevalence and pattern of CAM use among children attending the pediatric otolaryngology department in a tertiary pediatric teaching hospital in Scotland. DESIGN: A cross-sectional survey conducted by administering an anonymous questionnaire to the parents accompanying patients attending the pediatric otolaryngology department. Elective admissions and clinic attendees were included over a 3-month period in 2005/2006. SETTING: Academic tertiary care referral centre in North-East Scotland. PATIENTS: Five hundred and fifty-four consecutive patients aged less than 16 years were eligible. The response rate was 59% (n=327). MAIN OUTCOME MEASURES: Prevalence of CAM use in children. Secondary measures include types of CAM used, indications for use and communication with family physicians. RESULTS: Based on 327 responses, 93 patients (29%) had ever used CAM, 20% within the last year. Commonly used CAM preparations were cod-liver oil, echinacea, aloe vera, cranberry, primrose oil and herbal vitamin supplements. The popular non-herbal CAM included homeopathy, massage, aromatherapy, chiropractic, yoga and reiki. Nineteen percent used CAM for their admission illness. Sixty-one percent of parents thought that CAM was effective and 65% would recommend it to others. Fifty-one percent of parents stated that the family physician was unaware of CAM use by the child. CONCLUSIONS: Despite concerns regarding the efficacy, safety and cost effectiveness of complementary and alternative medicine, its use among the pediatric otolaryngology population is more common than many providers may realize. This has implications for all healthcare workers involved in their care.     

Adolescent otolaryngology

OBJECTIVE: To determine the pattern of disease amongst ambulatory adolescents referred to a pediatric otolaryngology outpatient department. METHODS: Retrospective chart review of adolescents newly referred to a tertiary pediatric otolaryngology outpatient department over a 12-month period. RESULTS: One hundred and fifteen patients were included (male 56, female 59) mean age 14.9 years. There were 36 (31%) patients who had previously required otolaryngology management for another condition, and 29 patients with complex medical conditions. Investigations, including audiology and medical imaging, were performed in 35 patients. The patients were managed surgically 34 (30%), medically 28 (24%), referred to other departments 10 (9%) had no intervention 21 (18%), while 22 (19%) failed to attend for follow up. CONCLUSION: Ambulatory adolescent patients present with a comparable spectrum of otolaryngological problems to other pediatric age groups. These patients appear to be well managed by pediatric otolaryngologists, and there does not seem to be a need to develop a free standing adolescent otolaryngology subspecialty within tertiary pediatric otolaryngology at this time.     

Safety and outcomes of outpatient pediatric otolaryngology procedures at an ambulatory surgery center

Objectives: To determine the safety and outcomes of outpatient pediatric otolaryngology procedures performed at an ambulatory surgery center (ASC). Methods: Retrospective review of all pediatric otolaryngology cases performed at a freestanding, outpatient ASC of a tertiary care, academic children's medical center from 2000 to 2007. Results: Of all cases, 4979 (55%) were otolaryngology procedures. Twelve surgeons and 10 pediatric anesthesiologists staffed the cases; no residents/fellows were involved. The case breakdown is as follows: 2045 (41.1%) myringotomy and tympanostomy tube; 1438 (28.9%) adenoidectomy (with tympanostomy tube placement and/or turbinectomy); 880 (17.7%) tonsillectomy (with or without adenoidectomy). According to American Society of Anesthesiologist (ASA) classification: 84.2% were ASA I, 15.1% ASA II, 0.7% ASA III. There were nine unanticipated outcomes: four postadenotonsillectomy and one postadenoidectomy bleeds (three requiring reoperation the same day), two patients with low psuedocholinesterase levels, one postadenotonsillectomy patient requiring overnight monitoring, and one patient with an incidental finding of a subglottic mass. Preoperative ASA status on these nine patients was 7 (78%) ASA I, 2 (22%) ASA II. Conclusions: Pediatric otolaryngology procedures constitute significant volume at our ASC. Surgery at our ASC is extremely safe with a rate of unanticipated outcomes of 0.2%—a comparison not available in the literature. Pediatric otolaryngology procedures performed with a highly skilled team at an outpatient ASC result in high quality and safe surgery.     

Use of potassium titanyl phosphate (KTP) laser in management of subglottic hemangiomas

OBJECTIVE: to study the role of KTP laser in management of subglottic hemangioma. DESIGN: retrospective analysis of patients with subglottic hemangioma treated by the senior authors. Setting: tertiary care teaching hospital. PATIENTS: twelve patients with subglottic hemangiomas. INTERVENTION: patients were treated with KTP laser (eight cases), CO(2) laser (two cases) or observation (two cases). MAIN OUTCOME MEASURE: resolution of symptoms, decrease in size of subglottic hemangioma or tracheotomy decannulation. RESULTS: All patients treated with KTP laser or CO(2) laser had resolution of symptoms and five tracheotomy-dependent children were decannulated. CONCLUSION: subglottic hemangioma is a potentially life-threatening disease seen in young children. Most authors recommend use of either CO(2) or open surgical excision. There is very little data available on the use of KTP lasers in the management of subglottic hemangiomas. The KTP laser beam is preferentially absorbed by hemoglobin making this laser system more applicable to the treatment of vascular tumors such as the hemangioma. KTP laser is a good tool for management of subglottic hemangioma with a low incidence of complications.     

Revision stapedectomy for otosclerosis: report of 73 cases

OBJECTIVE: The aim of this study was to determine causes and evaluate results of revision stapedectomy. DESIGN: Retrospective review of 73 revision stapedectomies. SETTING: Revision stapedectomies were performed in two tertiary otolaryngology departments (Fondation Adolphe de Rothschild, Paris, France, and Cliniques universitaires Saint-Luc, Bruxelles, Belgium). METHODS: Patients characteristics, indications for revision, intraoperative findings, and hearing results were noted. MAIN OUTCOME MEASURES: Hearing results were reported as recommended by the American Academy of Otolaryngology-Head and Neck Surgery. We also reported hearing results with and without the use of a laser. RESULTS: Conductive hearing loss was the main indication for revision (78%). Mean intraoperative findings included prosthesis malfunction (50%), fibrous adhesions (32.8%), incus necrosis (8.5%), and otosclerotic regrowth (7%). When revision was performed because of cochleovestibular complication, middle ear exploration revealed three findings: oval window granuloma (30.7%), perilymphatic fistula (30.7%), and a too long prosthesis (23%). Postoperative air-bone gap (ABG) was closed to less than 10 dB in 51.5% of cases and to less than 20 dB in 68.7% of cases, with 9% of sensorineural hearing loss (not exceeding 15 dB in 80% of cases). The use of an argon laser in 14 patients (19%) showed slightly better hearing results (postoperative ABG < 10 dB in 61.5% of cases and < 20 dB in 77% of cases), but this difference was not statistically significant compared with patients operated on without the use of a laser. CONCLUSION: The results of this series are comparable with previously published studies. Revision stapes surgery is not as successful as primary stapedectomy, but good gap closure can be expected in two-thirds of cases with an experienced surgeon.     

Partial promontory technique in stapedotomy cases with narrow niche.

OBJECTIVE: The objective of this study was to examine clinical and audiometric outcomes of a laser partial promontory technique in stapedotomy cases with a narrow oval window niche. STUDY DESIGN: We conducted a retrospective chart review. SETTING: This study was conducted at a tertiary referral center. PATIENTS: We studied 59 patients who underwent a partial promontory technique with stapedotomy between 1994 and 2000. Seventy-two patients who underwent primary stapedotomy without promontory technique served as a control group. METHODS: Preoperative and postoperative audiometric results were obtained for 59 patients undergoing laser stapedotomy with a narrow oval window niche. The partial promontory removal was performed with a KTP laser. Results were compared with 72 primary laser stapedotomy cases without the promontory technique within the same time period and analyzed using paired Student t test. RESULTS: Ninety percent of the partial promontory cases were successful (air-bone gap [ABG] <10 dB). The mean postoperative ABG was 5.1 dB, which was comparable to the non-promontory cases (p = 0.7). The mean change in postoperative bone conduction was also comparable (p = 0.98). There were no cases of sensorineural hearing loss. An overhanging facial nerve was present in 32% of the narrow niche cases and a dehiscent facial nerve was encountered in 17% of these cases. CONCLUSIONS: Partial laser removal of the promontory as an adjunct to laser stapedotomy cases with a narrow oval window niche is a safe, effective technique with comparable results to primary laser stapedotomy.     

Interrater and intrarater reliability in the evaluation of velopharyngeal insufficiency within a single institution

OBJECTIVE: To explore the interrater and intrarater reliability in nasoendoscopic assessment of velopharyngeal (VP) function using the standardized reporting method described by Golding-Kushner within a single institution. DESIGN: Prospective blinded study. SETTING: Academic, tertiary care, pediatric hospital. PARTICIPANTS: Six health care providers (2 pediatric otolaryngology faculty members, 2 pediatric otolaryngology fellows, and 2 speech pathologists) independently rated 50 videotaped nasoendoscopy segments twice. The segments on the videotape were obtained in a clinical setting. MAIN OUTCOME MEASURES: The Golding-Kushner rating system was used to rate VP function. Raters described VP closure quantitatively by rating palatal and lateral pharyngeal wall movement for each segment. They also qualitatively described characteristics of the VP gap, rated gap size as none, small, medium, or large, and estimated the percentage gap size relative to the resting position. Reliability coefficients were calculated for the data sets. RESULTS: Fairly good interrater and intrarater reliability was seen in the quantitative measures. Faculty otolaryngologists rated segments more similarly to each other than did pediatric otolaryngology fellows, but intrarater reliability was similar for both the experienced and less experienced otolaryngologists. Less consistency was seen in the ratings of the speech pathologists. Raters tended to rate with less consistency when describing qualitative characteristics of the VP gap than when making quantitative measurements. CONCLUSIONS: The Golding-Kushner scale is a reasonably reliable tool for reporting nasoendoscopic findings at our institution. However, these data also indicate that there exists room for improvement and that rater training may increase reliability.     

Classification and management of tracheoesophageal and tracheopharyngeal fistulas after laryngectomy

OBJECTIVES: Tracheoesophageal fistulas (TEF) and tracheopharyngeal fistulas (TPF) are intentionally created for prosthetic or surgical voice restoration after laryngectomy or can develop after radiotherapy or surgical interventions. If the fistula does not shrink or close spontaneously or does not respond to conservative measures, surgical closure of the fistula is indicated. STUDY DESIGN: Retrospective study of 177 patients. METHODS: Data of 168 laryngectomy patients who needed a voice prosthesis (VP) replacement were obtained. Our experiences with nine severe TEF/TPF were analyzed, and a classification of these fistulas depending on the anatomic and clinical appearance was developed. RESULTS: TEF/TPF can be divided into five types: high TEF with leakage through the VP (type Ia), high TEF with leakage around the VP (type Ib), enlarged high TEF (type II), deep TEF (type III), TPF (type IV), and TPF associated with pharynx stenosis (type V). Persisting TEF/TPF after unsuccessful attempts at surgical closure in four patients and the surgical solutions and procedures in these rare cases are discussed in detail. CONCLUSIONS: Leakage of TEF in prosthetic voice restoration usually responds well to conservative measures. If these measures fail, and in all cases of TPF, surgical intervention is necessary for transtracheostomal or transcervical closure with multilayer sutures of the esophagus and trachea. Persisting TEF/TPF after unsuccessful surgical attempts at revision surgery remain challenging. Our experiences show that tracheostoma transposition for dissociation of the cranial end of the trachea and the hypopharynx and esophagus is essential for effective closure. In rare cases of TPF combined with pharyngoesophageal stricture formation, a resection and immediate reconstruction of the stenotic pharyngoesophageal segment with a tube-shaped fasciocutaneous radial forearm flap must be considered.     

A comparison of the hearing results of KTP and Erbium YAG laser stapedotomy

Conclusion. Our data prove that lasers are safe and useful instruments in stapes surgery. Good postoperative results can be attained in both KTP and Er: YAG lasers. There was no significant inner ear damage related to the Er: YAG laser use. Objective. To compare the postoperative results of stapedotomies performed with KTP and Erbium: YAG lasers in patients with otosclerosis in order to assess the risk of Er: YAG for the inner ear. Patients and methods. The charts of 152 consecutive adult patients who underwent primary laser stapedotomies for otosclerosis from 1999 to 2005 were reviewed. One hundred and thirty-seven stapedotomies (98 patients) were performed using the KTP laser and 54 stapedotomies (54 patients) were performed with Er: YAG laser. All the patients were separated in two groups according to the type of laser, which was used. Hearing results were analyzed according to the Committee on Hearing and Equilibrium Guidelines of the American Academy of Otolaryngology—Head and Neck Surgery. Pure-tone audiometry was performed before the surgery, three months and one year postoperatively. Results. The study indicated that KTP and Er: YAG stapedotomies have similar rates of the air-bone gap closure. There was no significant postoperative sensorineural hearing loss found in both techniques.     

Endoscopic KTP laser excision of severe tracheotomy-associated suprastomal collapse

OBJECTIVE: The purpose of this study was to investigate the feasibility, safety, and clinical utility of potassium-titanium-phosphate (KTP) laser bronchoscopy for excision of severe, obstructing tracheotomy-associated suprastomal collapse. METHODS: A retrospective review was performed of six children at a tertiary care children's hospital with severe tracheotomy-associated collapse of the suprastomal anterior tracheal wall cartilage, precluding decannulation. All subjects had undergone KTP laser endoscopic excision of the collapsed segment of suprastomal tracheal cartilage. Medical records were assessed for: (1) endoscopic demonstration of relief of suprastomal collapse, and (2) successful tracheotomy decannulation. RESULTS: All six patients had endoscopic evidence of relief of suprastomal airway obstruction after KTP laser therapy. Five of six (83%) subsequently underwent successful decannulation. There was one case of minimal thermal airway injury associated with a laser fire during use of the KTP laser, the effects of which were fortunately transient. CONCLUSIONS: KTP laser bronchoscopic excision of severe tracheotomy-associated suprastomal collapse: (1) is a feasible technique; (2) results in relief of suprastomal obstruction with subsequent successful decannulation in selected patients; and (3) avoids the need for more extensive open neck procedures. However, risks of KTP laser therapy are not negligible and strategies must be in place to minimize the occurrence of complications.     

Flexible bronchoscopy and interdisciplinary collaboration in pediatric large airway disease

OBJECTIVE: Demonstrate the benefits of a multidisciplinary pediatric airway team prepared to evaluate and treat otolaryngology patients with flexible bronchoscopy. DESIGN: Case series. SETTING: Tertiary, academic children's hospital. PATIENTS: 10 children (5 male, 5 female age range 2 months-16 years) presenting with complex symptoms potentially referable to large airways. INTERVENTION: Flexible bronchoscopy for diagnostic (bronchoalveolar lavage, ciliary biopsy, assess ongoing surgical intervention, and rule in or rule out foreign body; N=6) or therapeutic (evacuate bronchial mucus plug, laser subglottis when patient has fused cervical spine, and distal instillation [fibrin glue for bronchopleural fistula and dornase alpha for plastic bronchitis]; N=4). MAIN OUTCOME MEASURE: Retrospectively ask if flexible bronchoscopy and interdisciplinary management improved patient care in these select otolaryngology cases. RESULTS: 10/10 patients benefited from interdisciplinary management including flexible bronchoscopy. CONCLUSION: Our experience illustrates many uses for flexible bronchoscopy in otolaryngology patients, and suggests that an airway team prepared to use flexible bronchoscopy will create opportunities for improved patient care.     

Treatment of tracheal and endobronchial lesions with the potassium titanyl phosphate laser.

Lower tracheal and endobronchial lesions represent a difficult management problem. While there has been some success in the treatment of these lesions with the carbon dioxide laser, the limitations of its delivery system have restricted its use in infants and neonates. The potassium titanyl phosphate (KTP) laser, transmitted via a flexible quartz fiber, can be precisely manipulated even through rigid pediatric bronchoscopes as small as 3.0 mm. In addition, the Hopkins telescopic lens may be used to improve visualization and control. We report our experience using the KTP laser to treat 15 pediatric patients with tracheal and endobronchial lesions. The nature of the lesions, the details of the technique, and the results are presented.     

Efficacy of treating children with anterior commissure and true vocal fold respiratory papilloma with the 585-nm pulsed-dye laser

OBJECTIVE: To report preliminary results regarding the safety and efficacy of the 585-nm pulsed-dye laser (PDL) for the treatment of juvenile-onset recurrent respiratory papillomatosis (JORRP) in the pediatric population. DESIGN: Prospective longitudinal cohort study. SETTING: Two pediatric otolaryngology referral centers. PATIENTS: Twenty-three pediatric patients ranging in age from 6 months to 17 years. INTERVENTIONS: The 585-nm PDL was used for at least 1 treatment on each of these patients to treat JORRP of the true vocal folds or anterior commissure. MAIN OUTCOME MEASURES: Complications from the use of the 585-nm PDL in the treatment of JORRP. RESULTS: There was no evidence of anterior commissure webbing or true vocal fold scarring in this group of 23 patients followed up for 3 months to 1 year. CONCLUSIONS: The 585-nm PDL seems to be a safe instrument for treatment of JORRP. There is the potential that improved voice outcomes may be apparent when compared with traditional therapies because the vocal fold epithelium seems to be unharmed when treated with this method. Furthermore, the lack of epithelial damage incurred by the 585-nm PDL should enable more aggressive surgical excision of anterior commissure disease. Further prospective longitudinal studies examining voice outcomes are needed.     

Office-based 532-nm pulsed KTP laser treatment of glottal papillomatosis and dysplasia

OBJECTIVES: Treatment of glottal papillomatosis and dysplasia was mirror-guided and done in surgeons' offices in the 19th century. It migrated to the operating room in the 20th century to accommodate direct laryngoscopic surgery, which required assistants to administer anesthesia and procedural support. The primary treatment goals, which are disease regression and voice restoration and/or maintenance, are tempered by the morbidity of general anesthesia and potential treatment-induced vocal deterioration. To obviate general anesthesia, office-based laser laryngeal surgery was first done in 2001 with the 585-nm pulsed dye laser (PDL), because it employs a fiber delivery system and its energy is selectively absorbed by oxyhemoglobin. Since then, this new angiolytic laser treatment paradigm has become a mainstay of management for many surgeons; however, there are a number of shortcomings of the PDL. To further develop this concept and address the limitations of the PDL, we used a 532-nm pulsed potassium titanyl phosphate (KTP) laser. METHODS: A prospective assessment was performed on 48 patients in 72 cases of recurrent glottal dysplasia (36) or papillomatosis (36). All individuals had previously undergone microlaryngoscopic management with histopathologic evaluation. RESULTS: Two dysplasia patients did not tolerate the procedure. Of the treatable dysplasia cases, there was follow-up in 29 of 34. Disease regression was at least 75% in 18 of 29 cases (62%), 50% to 75% in 7 of 29 (24%), and 25% to 50% in the remaining 4 of 29 (14%). Papilloma patients returned for treatment when symptoms recurred, so disease regression could not be assessed accurately. Similar to data obtained with the PDL, these data confirmed that dysplastic mucosa could normalize without resection. CONCLUSIONS: Our observations revealed that the 532-nm pulsed KTP laser provided enhanced performance over the PDL laser in a number of ways. The ability to use smaller glass fibers precluded mechanical trauma to the channels of the flexible laryngoscopes and allowed for improved suctioning of secretions. Oxyhemoglobin absorbs energy better at 532 nm than at 585 nm, and the KTP laser can be delivered through a longer pulse width. These factors provide enhanced hemostasis and improved intralesional energy absorbance. Finally, unlike the PDL, the KTP laser is a solid-state laser and is not prone to mechanical failure.     

Health provider determinants of nonattendance in pediatric otolaryngology patients

INTRODUCTION: Nonattendance for otolaryngology appointments disrupts the management of medical care and leads to ineffective use of resources. The determinants of nonattendance in pediatric otolaryngology patients have not been well documented. OBJECTIVES: To investigate health provider determinants of nonattendance in pediatric otolaryngology patients. STUDY DESIGN: We assessed the effects of waiting time for an appointment and the timing of the appointment (during the day, week, and year) on nonattendance proportions during a 1 year period. Chi square tests were used to analyze statistically significant differences of categorical variables. Logistic regression was used for multivariate analyses. RESULTS: A total of 2,628 pediatric visits were included in the study. The overall proportion of nonattendance at the pediatric otolaryngology clinic was 33.0%. Nonattendance proportions were 32.7% between 7 AM and 9 AM; 28.3% between 9 AM and 2 PM, and 36.5% between 2 PM and 8 PM (P < .001). The proportion of nonattendance was 24.1% when there was a short waiting time for an appointment (0-7 days), and 36.3% when there was an intermediate waiting time (7-15 days), and 36.6% when there was a long waiting time (15 days and above)(P < .001, P < .012, respectively). CONCLUSIVE: Health provider determinants of nonattendance in pediatric otolaryngology clinic appointments include the waiting time for an appointment and the hour of the appointment within the day.     

Pediatric ear foreign body retrieval: A comparison across specialties

ObjectivesTo analyze what characteristics of patients and/or ear foreign bodies should prompt referral to otolaryngology with the goal to maximize successful removal and minimize complications.MethodsThis was a retrospective chart review of pediatric patients who presented for ear foreign body removal from January to December 2016 at a tertiary hospital center. Data collection included successful removal, major or minor complications, use of general or conscious sedation, use of otic or oral antibiotics, age of patient, comorbid behavioral disorders, and foreign body characteristics. Major complications included tympanic membrane perforation or ossicular damage. Minor complications included injury of the canal wall. Patients with retained or extruded tympanostomy tubes were excluded.ResultsOf 275 patients aged 1–18 years, 16% presented initially to otolaryngology (ENT), 48.4% presented to the emergency department (ED), 21.8% presented to a pediatrician, and 13.8% presented to ENT after prior attempts at removal. Rate of successful retrieval by ENT was significantly higher than by PCP (95.4% vs 75.0%) or by ENT after prior failed attempts (65.8%), but not when compared to removal in the ED (85.7%). Retrieval by ENT after prior failed attempts had the highest rate of minor complications (26.3% vs 2.3–6.0%). There were two tympanic membrane perforations that were noted by ENT after prior failed attempts. Rate of operative intervention was significantly higher in patients who presented to ENT after prior attempts compared to patients who presented initially to ENT (34.2 vs 4.6%, p = 0.001). Of the patients who presented to ENT after previous failed attempts, there was a higher rate of complications and operative intervention if the patient was age 5 or under or the foreign body was difficult to grasp.ConclusionsPediatric ear foreign body presentation is common. Repeated attempts at removal are associated with higher rates of minor complications and operative intervention. Early consultation to otolaryngology should be considered if the foreign body is deemed difficult to grasp such as a bead or stone, especially if the patient is age five or younger.     

Optimizing effectiveness of laser tympanic membrane fenestration in chronic otitis media with effusion. Clinical and technical considerations

OBJECTIVE: To describe the patient, disease and clinical characteristics that optimize the effectiveness of laser tympanic membrane fenestration (LTMF) to treat chronic otitis media with effusion (OME). SETTING: Four pediatric otolaryngology tertiary referral centers. IRB approved; participation by informed consent. METHODS: An observational clinical effectiveness trial was conducted in 164 ears (94 children), who had chronic OME. All patients were candidates for insertion of pressure equalization tubes (PETs) but agreed to undergo LTMF instead. Clinical and audiologic follow-up are reported at 90 days after LTMF. OUTCOME MEASURES: Clinical effectiveness was defined as an effusion free middle ear at otoscopy with A or C1 tympanogram and normal hearing. RESULTS: At 90 days, 66% of the 95 evaluable ears were effusion free, all with normal hearing. Children younger than 4 years (P<0.04), who had shorter durations of effusion (P<0.009), and who experienced longer duration of fenestration patency (FP) (P<0.009) correlated to improved outcomes. CONCLUSIONS: The use of LTMF to create 2--3 weeks of middle ear ventilation in patients with chronic OME (middle ear effusion (MEE) for 3 months or greater) is effective in 66% of 95 (58%) of ears evaluable at 90 days follow-up. This study provides basic information needed to optimize the use of LTMF today and enhance research efforts in the future.     

Therapie der tracheoösophagealen und tracheopharyngealen Fisteln nach Laryngektomie

Tracheoesophageal (TEF) and tracheopharyngeal fistulas (TPF) after laryngectomy can mainly be divided into five types: “high TEF with leakage through the voice prosthesis (VP)” (Type Ia), “high TEF with leakage around the VP” (Type Ib), “enlarged high TEF” (Type II), “deep TEF” (Type III), “TPF” (Type IV) and “TPF associated with pharynx stenosis” (Type V). Leakage of TEF in prosthetic voice restoration usually responds well to conservative measures. If these measures fail, as well as in all cases of TPF, surgical intervention is necessary for transtracheostomal or transcervical closure with multi-layer sutures of the esophagus and trachea. In persisting TEF/TPF after unsuccessful surgical attempts revision surgery remains challenging. Tracheostoma transposition for dissociation of the cranial end of the trachea and the hypopharynx and esophagus is essential for effective closure. In rare cases of TPF combined with pharyngoesophageal stricture formation a resection and immediate reconstruction of the stenotic pharyngoesophageal segment with a tube-shaped fasciocutaneous radial forearm flap must be considered.     

The effect of treatment for epistaxis secondary to hereditary hemorrhagic telangiectasia

BACKGROUND: Epistaxis is the most common symptom in patients with hereditary hemorrhagic telangiectasia. Different treatment options have been described but with little reference to their effect on quality of life or disease severity. METHODS: This study prospectively investigated the effect of nasal closure, argon laser, and a combination of septodermoplasty and argon laser treatments on quality-of-life scores and disease severity ratings in a group of 29 patients with moderate to severe epistaxis referred to a tertiary referral center. RESULTS: The only group of patients who showed a significant improvement (p < 0.05) in quality of life were those who underwent nasal closure. In addition, the nasal closure patients were the only group in which there was a complete cessation of bleeding. CONCLUSION: Nasal closure should be offered to patients with moderate to severe epistaxis secondary to hereditary hemorrhagic telangiectasia that has proved unresponsive to other treatment.